Blue Cross/Blue Shield Medical Insurance

Questions

• Pediatric groups not taking Blue Cross
• Rejected for coverage by Blue Cross

Pediatric groups not taking Blue Cross

March 2004

I am trying to find a pediatrician for my daughter and the two main pediatric offices in the East Bay don't accept my insurance plan - Blue Cross PPO. I find it unacceptable that the plan I am paying monthly to have, won't provide care at either of the two major pediatric offices in my neighborhood. Who do I complain to -- the insurance, the doctors? I've tried asking my husbands employer if we can switch to an HMO plan, but that is not an option. Any ideas out there?? - I miss Berkeley Pediatrics

We are on Blue Cross PPO and see the physicians at the Pediatric Medical Group in Berkeley (2320 Woolsey). We've been very happy with everyone in this office, and we think the world of them! Katie

I am a physician in Berkeley who does not accept Blue Cross PPO, and I understand your frustration about having insurance with this PPO. Most medical offices who drop their contracts with this carrier do so because the carrier pays equal or less than Medi-cal rates to the medical providers. I don't suggest complaining to the doctor's about it, you can rest assured that they all attempted to negotiate a fair reimbursement rate with Blue Cross but were unsuccessful in doing so. No medical provider drops these contracts easily; we all know! we are affecting our patients when we do.

If this insurance is through the workplace, you should be contacting your human resources department about the inadequacy of the medical coverage they are purchasing for you. Complain also to Blue Cross. Ask them what they reimburse the physicians who are contracted with them. They will probably tell you that that is proprietary information. Rememember, you and your workplace are the consumers, should you be purchasing a product without knowing what you are buying? Lastly, fight for the opportunity to switch plans. Good Luck Elizabeth

We had this problem, too, just after Berkeley Peds. dropped Blue Cross PPO. The doctors will tell you to blame the insurance company; the insurance company will tell you to blame the doctors. Truth is, they both failed to negotiate after a certain point. It's been several years now, and I have not heard anything getting any better. We transferred to Pediatric Medical Group, and after a couple of years, I can tell you I am so glad we switched! I like this office much better, and it's a huge relief to be able to concentrate on the health of my child rather than the battles between billing and insurance. Carolyn

I understand your frustration. We ran into that when my husband left his job and we h! ad to change our health plan. We now have Blue Cross PPO and I was very disappointed to discover that Berkeley Pediatrics didn't accept Blue Cross. I had Dr. Franks, who I loved, and she said that they stopped accepting Blue Cross because they were having problems with them. It sounds to me like you would have to complain to the medical group or docter. But I don't think you can really achieve anything. They've made their decision. I did discover Kiwi Pediatrics takes Blue Cross. Both Dr. Kittams and Dr. Winoukur were recommended to me by Dr. Franks. We use the practice on San Pablo Ave. They have great nurse practioners there. We are happy with them. It is hard to swithch docters when you are happy with who you've got. Some people love their docters so much that they are willing to pay a higher price if their insurance doesn't cover. Check out Kiwi. They have two offices, one on Alcatraz Ave 652-1720, and one on San! Pablo Ave, near Gilman, 524- 9400. Good luck. Laurey

My daughter's healthplan is also Blue Cross PPO. I have found them easy to work with. We currently go to Primary Pediatrics in Oakland near Summit Hospital. The address is 411 30th St. Ste. 212. There are many good doctors in the practice. We have just started seeing Laura Saldivar, who we really like. The phone number is 510-433-1040. It is usally easy to get an appointment. They do drop-in almost most mornings, including saturday until 11am. And the receptionist and nurses are very personable. M

Rejected for coverage by Blue Cross

May 2003

My husband's company closed down 6 weeks ago and at that time we applied for private health insurance online through eHealthInsurance and chose BlueCross (which we had already had through his former employer). Six weeks later, ie now - today, we have received an email saying we are rejected for unspecified reasons and will get a letter about it sometime. We have no pre existing conditions in the family and virtually no health issues whatsoever! We are furious and dumbfounded, and don't really understand what do do now. We are already no longer covered and don't want to risk waiting another six weeks to find out the result of another blind application, but also can't afford to pay the Cobra ''back 2 months'' of $700.00 per month. Please any advice about this would be so helpful. What should we do? How can we get honest answers and decent service? Judith

Last year, my husband and I were also rejected when we applied independently for insurance, also through ehealthinsurance.com (but with Blue Shield). It was a huge learning experience. Mainly, when you apply independently for health insurance they can reject you for any small/large reason -- or no reason at all (which has been happening more and more lately since the economy is bad and insurance companies are taking fewer risks). Whereas when you apply through a group -- insurance companies care less about you as an individual because they figure most in the group will be healthy and a few sick. My advice is to fight their decision. Once you get their letter, call the 800 number on it, and try to get as much information about the reason for your rejection as possible. Then write a formal letter asking to appeal their decision and your reasons why. Then continue to call and follow-up with them until you hear back on the appeal (can take 6 weeks to 3 months). But very few people appeal and there's a good chance they'll reverse their decision if you bug them. They reversed their decision for my husband and I but, I admit, the experience was somewhat degrading and eye-opening on the whole health insurance world. anon

We've been through something similar to this twice. What we learned was Get an insurance broker. One who handles several insurance companies is best, because she or he can help you maneuver through the options and the application, get you over the various hurdles, and tell you why one company's deal is better for you than some others'. Also, now that you've been denied, when you apply to other comnpanies, you have to admit that fact. This will make it harder to get insurance. Fighting the rejection could take months. You might easily have been rejected for some seemingly minor thing (my child was rejected for having had three ear infections as a two-year-old). You might have been rejected for errors in your medical records (as I was). Getting all this straightened out can take a long time. Meanwhile, you'll lose your Cobra option, and then you'll basically be uninsurable. Having been through all this myself, I suggest biting the bullet and some how paying the Cobra. When the Cobra ends, even if you do have health problems (like ear infections -- ear infections! What two-year-old doesn't have ear infections?) you will be eligible for ''guaranteed issue'' insurance, which is available to anyone who has had their Cobra options run out, even if that person has health issues. Again, a broker is strongly recommended. A broker can help you through all this, and will cost you nothing extra at all. Good Luck! --Been There

My experience is that they routinely reject people for what seems like no reason. I would get yourself a broker and work through them- they can give you lots of advice and advocate for you with the insurance companies. We use Myers Stevens 415-543- 4040 and I have been very happy with them. Good luck! Juliette

We went through this exact same thing with Blue Cross PPO indiv. plan when my husband switched jobs to a start up that had no benifits. We wanted to get pregnant and had to wait *5 months* to start trying until we were finally accepted b/c they won't take ''pre-existing conditions''. When we called they said we may get regected because I have asthma and also take paxil a few days per month for pms, and my husband might get regected because he once told his doctor his back was a little stiff and back problems are also pre existing!

What we did was keep calling blue cross. They even told us if we got regected once to re-apply and let them requisition all our doctors for our medical records. They ended up accepting us the first time, but not until they called every one of our docs for the past 5 years (including my 3 yr old son's) and pouring over our records.

It sounds to me like maybe the online process didn't get the close attention you needed. I would advise calling a representative and asking them to look at your case and pinpoint the problems, and find out exactly who was regected, you or your husband.

We all had to apply separately (not as a family), on our own individual plans for them to take us. You should ask them if they would encourage you to re-apply. If they don't sound encouraging, call back another time and get a different representative. We almost didn't apply b/c one person discouraged us. Then when we called back the next day we got someone better who helped us follow our case all the way through. If this happens, call Blue Cross back every week or so, through each step of the process until the end to make sure your case is getting the proper attention. We found if we call back and politely enquire (e.g. have they requested records from our docs yet, did they get the forms we sent, is there anything we can do to help the process etc), emphasizing how worried we were and how important this was to us, that it went a long way to get them to pay attention to our case.

You might also try other health insurances.It is a bit more difficult once you have been rejected by one, but I've heard if you are honest and keep trying, you can get accepted, it just may take a long time. Fortis takes almost anyone, but they don't have maternity coverage in California. so I guess they take mostly men ;-)

I'm sorry this happened to you, I know how frustrating it is. We were dumbfounded by how hard the process was!

Now we are pregnant and happily insured! I hope it works out for you, too.

Been there for five months of awful waiting! anon

You are not alone in your experience with Blue Cross. Just hearing about your experience makes my blood pressure go up! Having been through almost the exact experience as you, I can recommend what we did. We got advice and help from a really smart broker, after being sucked dry by high COBRA bills and a long tale of horrors with Blue Cross. With our broker's help we swtiched to the only non-profit insurer left, Blue Shield. Blue Shield is far from perfect but much better than the others. We prefer a PPO with a high copay and high deductible which is offset by a lower premium. We've been self employed for 17 years, with two children, and this type of policy has served us well. The broker I swear by is Bob Copeland, Copeland Insurance of Larkspur, CA. 415-461-6137. Good luck to you. If anyone can help you , Bob can. Burned by Blue Cross, but only once!

We went through the same problems you had, but were rejected by Blue Shield. We went through the process of appealing the decision, to no avail. (They don't make it easy.) Finally, we applied to HealthNet, and were approved - we did let them know about our rejection from BS. Instead of paying Cobra's high rates, you can go to a broker and get a temporary insurance policy for your family (only covers catastrophic injury) at a very reasonable rate per month. Good luck! Kim

We too were rejected by Blue Cross -- as well as just about everyone else -- right after my husband was laid off. We're a young healthy family, but my husband takes an expensive prescription drug and that was enough to keep us from getting insurance. I posted to this list and someone suggested health insurance broker Tony Uccelli who was really a godsend. He was incredibly helpful in finding an affordable solution for us, and we are all now happily insured (although not all by the same insurer). I can't seem to locate his number at the moment, but he's in the 650 area code. Good luck! nelly